A pregnant client with a history of heroin use is admitted to the birthing unit. The client is currently in a treatment program and has been on stable doses of methadone during her pregnancy. She tells the nurse, “I know my baby may go through withdrawal after delivery. What will happen?” The nurse correctly tells her that her baby may: (Select all that apply)
Sleep deeply.
Have a high-pitched cry.
Not feed well.
Have some shaking.
Sweat a lot.
Correct Answer : B,C,D,E
Choice A rationale
Deep sleep is not a characteristic of neonatal abstinence syndrome; rather, infants tend to exhibit irritability and disturbed sleep patterns due to central nervous system hyperirritability caused by opioid withdrawal.
Choice B rationale
A high-pitched cry occurs due to central nervous system overstimulation and hyperirritability, which are hallmark features of neonatal abstinence syndrome and a direct result of opioid withdrawal in neonates.
Choice C rationale
Poor feeding is common in neonatal abstinence syndrome due to uncoordinated suck reflexes and gastrointestinal disturbances, leading to difficulty maintaining adequate nutrition and hydration in affected neonates.
Choice D rationale
Neonates with neonatal abstinence syndrome often exhibit tremors or shaking as a result of central nervous system hyperirritability, which is a hallmark symptom of opioid withdrawal in newborns.
Choice E rationale
Excessive sweating is a manifestation of autonomic nervous system dysregulation caused by opioid withdrawal in neonates, commonly observed in infants with neonatal abstinence syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Infection of the uterus typically presents with fever, foul-smelling lochia, and uterine tenderness, not bright red vaginal bleeding with a firm fundus. Firm fundus decreases the likelihood of retained products causing infection.
Choice B rationale
Uterine atony causes excessive vaginal bleeding due to the uterus's inability to contract effectively, but it doesn't apply here since the fundus is firm, indicating adequate uterine tone.
Choice C rationale
Perineal hematoma results from blood vessel damage during delivery. It causes a tense, painful mass and vaginal or perineal swelling, not steady, bright red bleeding with a firm fundus.
Choice D rationale
Lacerations of the genital tract result in bright red bleeding despite a firm fundus, as the bleeding originates from tears in the vaginal or perineal tissues rather than uterine atony.
Correct Answer is D
Explanation
Choice A rationale
Gastric problems later in life, such as gastrointestinal motility issues, may occur in infants with myelomeningocele but are not an immediate risk requiring urgent intervention.
Choice B rationale
Respiratory depression is not a direct consequence of myelomeningocele unless associated with other congenital anomalies or complications like Chiari malformation affecting brainstem function.
Choice C rationale
Decreased cardiac output is not a primary concern in myelomeningocele unless secondary to severe infection or other systemic complications, which are less immediate risks.
Choice D rationale
Infection is the greatest immediate risk due to the exposed neural tissue in myelomeningocele, which provides a direct pathway for pathogens, necessitating prompt surgical closure and sterile management.
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